Please check if the patient has a history of the following medical conditions:

Yes

No

Acid Reflux

Yes

No

ADHD/ADD

Yes

No

AIDS/HIV

Yes

No

Anemia

Yes

No

Arthritis

Yes

No

Asthma

Yes

No

Autism

Yes

No

Bone Disorders

Yes

No

Cancer

Yes

No

Cerebral Palsy

Yes

No

Chest Pain

Yes

No

Chronic Neck Pain

Yes

No

Clicking of Jaw

Yes

No

Jaw Pain

Yes

No

Cold Sores/Herpes

Yes

No

Diabetes

Yes

No

Down Syndrome

Yes

No

Endocrine Problems

Yes

No

Emotional Disorders

Yes

No

Epilepsy

Yes

No

Headaches

Yes

No

Heart Condition

Yes

No

Hepatitis

Yes

No

Ear Pain

Yes

No

Immune Problems

Yes

No

Kidney Problems

Yes

No

Low Blood Pressure

Yes

No

Muscular Disorders

Yes

No

Nervous Disorders

Yes

No

Organ Transplant

Yes

No

Osteoporosis

Yes

No

Painful Chewing

Yes

No

Periodontal Problems

Yes

No

Prolonged Bleeding

Yes

No

Rheumatic Fever

Yes

No

Scoliosis

Yes

No

Seizures

Yes

No

Sinus Problems

Yes

No

TMJ Problems

Yes

No

Tuberculosis

Yes

No

Do your gums bleed when you brush?

Yes

No

Is the patient seeing any other dental specialists?

Yes

No

Any dental restorations needing to be completed?

Yes

No

Have there ever been any injuries to the face, mouth or chin?

Yes

No

Have you ever lost or chipped any teeth?

Yes

No

Do you have any pain or soreness around your face, neck or back?

Yes

No

Is any part of your mouth sensitive to temperature or pressure?

Yes

No

Is the patient currently pregnant?

Yes

No

Have adenoids been removed?

Yes

No

Have tonsils been removed?

Yes

No

Currently taking any medications?

Yes

No

Are antibiotics necessary prior to treatment?

Yes

No

Allergies?

Yes

No

Any diseases or problems not mentioned above?

Please check if the patient has, or ever had, any of the following habits?

Yes

No

Cheek, tongue or lip biting

Yes

No

Clenching Teeth

Yes

No

Fingernail Biting

Yes

No

Grinding Teeth

Yes

No

Tongue Sucking

Yes

No

Thumb Sucking

Yes

No

Tongue Thrusting

SIGNED CONSENT

I understand the information given is correct and will be held in the strictest confidence. I also understand that it is my responsibility to inform this office of any changes in the patient's medical status.

I hereby authorize this office to perform an oral evaluation and consent to the taking of x-rays, photographs and other records (if necessary) to determine appropriate orthodontic treatment on the above-named patient.

I also authorize this office to leave messages about appointments on my voice mail or answering machine, and agree to receive e-mail reminders and text messages about appointments.

Typed Name/Signature

Relationship to Patient

Date

If someone other than the parent(s) or guardian(s) listed above will be bringing the patient to appointments, please list here:

By submitting this form you agree to the above mentioned consent statement